Incident Investigation follow

Table 14-4 offers ways for optimizing the effectiveness of incident investigation follow-up. Not all options are appropriate for all investigation management systems or every investigation. The reader should determine which ones should be used and where. 

Are the incident investigation follow-up expectations clearly stated in the incident investigation policy statement ... 

If incident case studies are periodically communicated to executives, they can help to reenforce the importance of doing things correctly. This typically translates into critical tasks that must he performed hy skilled workers and accoimtahility for those activities at an executive stewardship level. Such a commitment will carry over into incident investigation follow-up. 

The major components of a compliance system are regular inspections, reporting, incident investigation, follow-up, enforcement, and recognition and reward. The system should emphasize fact finding, not fault finding. That applies to all the safety and security programs and policies described in Chapter 3. Initiation and maintenance of an effective compliance system are important to ... 

Most incident investigations follow formal procedures. This chapter discussed two of the most common procedures change analysis and job hazard analysis. An investigation is not complete until a final report is issued. Responsible individuals can use the information and recommendations to prevent future incidents [6]. 

The employer investigates incidents that result in, or could result in, a catastrophic release of highly hazardous chemicals. An incident investigation is initiated as soon as possible, but before 48 hours following the incident. An incident investigation team is established to consist of one or more experts in the process involved, and accident investigation. The report prepared at the conclusion of the investigation includes at a minimum ... 

Incident Investigation Major incidents Near-miss reporting Follow-up and resolution Communication Incident recording Third-party participation as needed... 

Three major themes have been emphasized in this chapter. The first is that an effective data collection system is one of the most powerful tools available to minimize human error. Second, data collection systems must adequately address underlying causes. Merely tabulating accidents in terms of their surface similarities, or using inadequate causal descriptions such as "process worker failed to follow procedures" is not sufficient to develop effective remedial strategies. Finally, a successful data collection and incident investigation system requires an enlightened, systems oriented view of human error to be held by management, and participation and commitment from the workforce. 

The first case study describes the application of the sequentially timed event plotting (STEP) technique to the incident investigation of a hydrocarbon leak accident. Following the analysis of the event sequence using STEP, the critical event causes are then analyzed using the root cause tree. 

The regulation states An incident investigation shall be initiated as promptly as possible, but not later than 48 hours following the incident. In part, the reason for this quick response to an incident is to assure that all pertinent evidence and facts can be preserved to facilitate the investigation. 

The results of environmental monitoring exercises will be influenced by a variety of variables including the objectives of the study, the sampling regime, the technical methods adopted, the calibre of staff involved, etc. Detailed advice about sampling protocols (e.g. where and when to sample, the volume and number of samples to collect, the use of replicates, controls, statistical interpretation of data, etc.) and of individual analytical techniques are beyond the scope of this book. Some basic considerations include the following, with examples of application for employee exposure and incident investigation. 

Incident Investigation—In assessing this element, consideration must be given to major incidents, near-miss reporting, follow-up and resolution, communications, incident recording, and third-party participation as needed. 

Also note the following temperatures of interest to process safety incident investigation teams (Perry and (ireen, 1997 NFPA 422M NFPA 1997 and Avallone and Baumeister, 1996). 

VII Recovery Procedures Procedures that explain the necessary actions following the response to the emergency. These include Incident investigation, employee support, community coordination, critiques, decontamination and recovery operations. 

This chapter provides an overview of a management system for investigating process safety incidents. It opens with a review of management responsibilities and presents the important features that a management system must address to be effective. It examines systematic approaches that help implement incident investigation teams, root cause determinations, recommendations, follow-up, and documentation. 

Making initial notification in a timely manner can present serious challenges immediately following an incident. The incident investigation management system should address how to handle these communications and how to coordinate with facility emergency response plans. A checklist with prearranged names, titles, and phone numbers should be developed and kept up to date for this use. 

Some companies choose to issue a follow-up report summarizing the status of action items related to incident investigations. It can be a useful tool for keeping the entire plant management staff up-to-date on what has been done and what is left to do to prevent recurrence. 

A classic incident theory is H.W. Heinrich s domino theory of causation, which has had a significant influence on practical incident investigation. (2) Many adaptations of Heinrich s original proposal have been developed by later researchers. Heinrich labeled his five dominoes as follows ... 

For example, failure to follow procedures is not a root cause. Failure to follow established procedure is a common premature stopping point for incident investigation related to human factors. In many cases, the... 

An incident has just been reported. How is a team activated The team activation segment of a company s incident investigation management system should guide the user to assemble a team based upon the following two areas of concern ... 

After each incident investigation, the team should ask the following questions to review important aspects of their performance ... 

The following equipment has been found useful for incident investigation. Not all is needed or appropriate for every investigation, but should be potentially available on short notice. 

An overview of the interviewing process is shown in Figure 8-7. The interviewing techniques discussed in the following section are generic to any interviewing activity, but have been modified to incorporate specific issues unique to incident investigation. 

In addition to the physical data analysis methods, traditional engineering analysis tools and methods are also useful during incident investigations. Traditional analysis tools can he used to determine the following. 

If the incident investigation team is satisfied with the root causes identified, then the investigation proceeds to the recommendation stage. If a problem or some incompleteness is noted, then an iterative loop is followed. 

The incident investigation team is responsible for developing practical recommendations and submitting them to management. It is then the responsibility of management to approve, modify, reject, communicate, implement, and follow-up on the recommendations, including ... 

For improved quality of formal written incident reports, the incident investigation team should follow these guidelines ... 

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